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Coverage, capacity, and constraints of private sector health facilities in Somalia

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Reporting back from the fifth Global Symposium on Health Systems Research

The fifth Global Symposium on Health Systems Research has recently concluded in Liverpool, with the theme ‘Advancing health systems for all in the SDG era’.

I spoke on a panel about engaging the private sector, and how private providers and private finance can support the achievement of the Sustainable Development Goals (SDGs); my paper was called ‘Half a loaf is better than none: coverage, capacity, and constraints of private sector health facilities in Somalia’. 

Background and our findings

The longstanding conflict and fragility in Somalia has resulted in parallel and fragmented healthcare system. In the absence of functioning public sector facilities, the country’s healthcare system has vertically privatised. Despite the crucial role of the private sector, there has been extremely limited evidence on this sector – and so, during 2016-17, we carried out a comprehensive mapping exercise using an innovative and cost-effective telephone interviewing method. This took place in all 9,675 UN p-code areas to identify the private sector health facilities, to assess their capacity, and to understand the constraints. A large number of interviews with patients, key informant interviews with providers, and focus group discussions with users in 30 private health facilities helped to better understand the demand side factors, including financial.

We identified approximately 3,500 private health facilities across Somalia, and were able to interview two-thirds of these. Our modelling enabled us to estimate that there were 2.2 private health facilities per 10,000 population (including pharmacies) or 0.93 per 10,000 (excluding pharmacies), and 4.89 private health workers per 10,000 population, compared with 4.28 per 10,000 in public sector. Among the facilities, 6% are hospitals, 32% clinics, 4% are diagnostic centres and 58% are pharmacies. Excluding the pharmacies, the private health facilities have an average of 1.2 qualified doctors, 1.1 clinical officers, 1.9 nurses/midwives and 1.2 pharmacists per facility.

The service availability is very mixed, with 66% hospitals offering 24-hours emergency services, 31% with the facility to carry out caesarean section, and 25% of the clinics offering immunisation. The out-of-pocket expenditure is very high, and a significant proportion of the users are getting care for non-communicable diseases at these health facilities – this contradicts the known disease profile of the country.

The future

This is the first comprehensive research on the private sector in health in Somalia, and the findings reaffirms the importance of the private health sector in the country, highlighting a number of areas of concern relating mainly to quality and coverage. Looking to the future of health policy in the country, our study underlines the need for a public-private partnership strategy to engage the private sector effectively in delivering healthcare in Somalia.